Provider Demographics
NPI:1790837474
Name:BRANDT CHIROPRACTIC CLINIC, PC LLC
Entity Type:Organization
Organization Name:BRANDT CHIROPRACTIC CLINIC, PC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROLD
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-854-3398
Mailing Address - Street 1:246 S INTEROCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:CO
Mailing Address - Zip Code:80734-1535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:246 S INTEROCEAN AVE
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:CO
Practice Address - Zip Code:80734-1535
Practice Address - Country:US
Practice Address - Phone:970-854-3398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3381111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U23748Medicare UPIN
COC27433Medicare ID - Type Unspecified